Learning Objectives
By the end of this section, you will be able to:
- Describe best practices for performing a cultural assessment
- Explain the models and theories that guide cultural assessment
- Explain the impact of a cultural assessment on patient outcomes
Completing a cultural assessment on a patient is important for nurses to provide holistic and patient-centered care. A cultural assessment is a method for systematically gathering information about a patient’s cultural beliefs, values, practices, and perceptions as they relate to health care. A cultural assessment enables nurses to deliver care that respects individual cultural values, beliefs, and practices. By incorporating cultural consideration into nursing assessments, interventions, and care planning, nurses can improve health outcomes, enhance patient satisfaction, and contribute to the elimination of health-care disparities.
Performing a Cultural Assessment
A cultural assessment of a patient can take on many forms but should address some main factors that can easily be overlooked in a health-care setting. Assuming that all people are the same and view the world through the same lens is not a way to provide patient-centered care. Best practices for performing cultural assessments are informed by the work of numerous theorists. A model by Giger and Davidhizar is widely used.
Giger and Davidhizar’s Transcultural Assessment Model
Giger and Davidhizar’s Transcultural Assessment Model is a model used by the nursing and medical professions to providing culturally competent care to diverse patient populations (Giger & Davidhizar, 2002). Marilyn Giger and Ruth Davidhizar as nurse researchers and theorists contributed to transcultural nursing with the development of the Transcultural Assessment Model. The model is a standardized approach to assess cultural factors in nursing practice. The purpose of the model is to guide nurses in conducting a comprehensive and culturally sensitive assessment of patients by collecting data on the impact of cultural factors on health beliefs, health care–seeking behaviors, and treatment preferences (Giger & Davidhizar, 2002).
Link to Learning
Read this article on transcultural nursing to learn more about Giger and Davidhizar’s Transcultural Assessment Model and to see a visual of its application to nursing practice.
The Transcultural Assessment Model includes considering language barriers, nonverbal cues, and culturally appropriate communication styles, and understanding cultural perspectives on time, attitudes toward punctuality, scheduling, and the perception of illness (Giger & Davidhizar, 2002). The nurse must also recognize biological differences influenced by ethnicity, genetics, and race that may impact health outcomes. An example is the importance of recognizing that Black Americans are at higher risk of developing hypertension or sickle cell anemia. Cultural factors also influence the prevalence of high-risk behaviors such as substance misuse, unprotected sex, or unhealthy dietary practices. Nurses must assess and be aware of patient dietary restrictions, such as Orthodox Jewish people who request the kosher eating practice of not combining meat and dairy foods together and having food blessed by a rabbi. Pregnancy and childbearing practices are also impacted by culture as are rituals surrounding death, dying, and end-of-life care.
Cultural Considerations
When performing a cultural assessment, the views around several important concepts should be explored. These concepts are time, space, communication, social organization, environmental control, and biological variations. The following sections explore what is meant by each of these concepts and how they impact cross-cultural health-care experiences.
Communication
The concept of communication varies among different cultures due to a range of factors, including language, nonverbal cues, communication styles, and cultural norms. Communication is a complex process influenced by cultural values, beliefs, and practices, and even defined roles within the culture.
Cultural Context
Decision-Making across Cultures
Although it is assumed that people aged 18 years or older make their own decisions, that is not the norm in all cultures and family structures. For example, in the Hispanic patriarchy, the dominant male is in charge as the key decision-maker. In some African American cultures, the matriarch is considered a key decision-maker and must be counseled for family decisions. Social status within the Japanese culture may require the son of older parents to be the sole decision-maker, even if the eldest child or children are daughters. It is important to include the appropriate members of your patient’s family to ensure everyone has the correct information and informed health-care decisions can be made.
Language plays a fundamental role in communication. All languages have distinct language patterns, such as dialects or slang, that can pose challenges in conveying and understanding messages accurately. Health-care professionals should be aware of language differences even within the same culture and utilize certified medical interpreters or translation services when necessary to ensure clear and accurate communication with patients. It is important to find out what language services are available at your health-care facility, including telephonic, live interpreters, or even the use of live streaming for American Sign Language services.
Communication includes both verbal and nonverbal elements, with 90 percent of messaging coming mainly from nonverbal communication, which includes body language, facial expressions, gestures, and eye contact (Park & Park, 2018). In some cultures, eye contact may be seen as a sign of attentiveness and respect, such as in North American culture, while in others, it may be considered disrespectful or confrontational, as in American Indian or Asian cultures. Being sensitive and aware of these differences helps health-care professionals avoid misinterpretations and misunderstandings.
Communication styles can vary along a continuum, ranging from direct to indirect. In some cultures, direct communication is preferred, which is expressing thoughts and opinions explicitly, such as in North American or German cultures. However, in other cultures, such as American Indian or Asian cultures, indirect communication relies on nonverbal cues and context. Hierarchical structures represent the way individuals identify authority figures and social structure, and these also vary within cultures. Many cultures have a male hierarchy, which traditionally gives authority and preference to males making key decisions.
Clinical Judgment Measurement Model
Analyze Cues: Determining Communication Style
Ms. Gonzalez has been admitted to the medical-surgical unit for a urinary tract infection. She seems very quiet and won’t give the nurse a medical history. Twenty minutes later, her husband arrives on the unit and asks to speak to the nurse. When the nurse arrives, Mr. Gonzalez admits that his wife knows little English and that he can answer any questions the nurse has. The nurse decides to utilize a medical interpreter, who reveals that Ms. Gonzalez would prefer her husband to be in the room for all conversations.
The nurse compares the closed-off body language of Ms. Gonzalez before her husband arrived to the more open, relaxed body language she exhibits now that he’s in the room. The nurse makes a note in the chart to have a medical interpreter and the patient’s husband available for any care conversations or education.
Another element of cultural communication is high context versus low context, which considers the amount of implicit information shared. High-context communication requires an understanding of the background of the situation and person. For example, eye contact and physical touch can be interpreted in many ways without a context. In contrast, low-context communication, such as clear verbal communication and concise written communication, does not need additional context and conveys what someone is saying without having to read into a double meaning.
Cultural norms regarding politeness, formality, and respect can significantly impact communication. For example, some cultures prioritize maintaining harmonious relationships and may use indirect language to convey messages or avoid confrontation. In contrast, other cultures may value directness and explicitness. Being aware of these cultural variations helps health-care providers navigate sensitive topics and maintain effective communication. A nurse may be puzzled why a family is not making a critical health-care decision, but knowing there are layers of meaning and cultural implications may help the nurse develop more empathy.
Because communication is so complex, even when we speak the same language, remember that asking a patient an open-ended question to explain what they understand is better than asking the closed-ended question of if they understand.
Time
The interpretation of the concept of time varies among different cultures, and it significantly influences individual’s behaviors, attitudes, and expectations. Some cultures may have a stricter monochronic approach to completing tasks on time, while others may complete multiple tasks at once and not pay a lot of attention to time. In health-care settings, understanding these cultural variations in the interpretation of time can help health-care providers communicate effectively, manage appointment scheduling, and address patient expectations. Being aware of these differences allows for more culturally sensitive and patient-centered care delivery.
Space
The concept of space is an important cultural concept for nurses to understand because it ,significantly influences patient care and interpersonal interactions. In the context of health care, space refers to the physical, psychological, and social dimensions that affect human relationships and communication. Respect for personal boundaries is important as different cultures have varying norms and expectations regarding personal space. Some cultures, such as the Latinx culture, may value closer physical proximity during interactions, while others may prefer more personal space, such as the Asian culture. Being aware of and respecting these differences fosters trust, enhances patient comfort, and promotes effective communication. Cultural norms regarding personal space and touch can differ significantly. An example is a female nurse who is unfamiliar with Japanese culture could inadvertently offend an older adult male when she goes to grab his arm to check his dialysis shunt without asking permission first. Another example is the offense a female Muslim patient may take if cared for by a male nurse who is trying to offer personal hygiene care.
Privacy is a fundamental right for patients, and nurses must honor this patient right. Honoring privacy respects patient’s privacy and confidentiality. It involves providing adequate physical space for confidential discussions, ensuring appropriate privacy measures of closing doors or dividing curtains, and considering cultural norms when determining the level of privacy required for different individuals. As with any patient, nurses can design spaces that promote relaxation, reduce anxiety, and encourage a sense of peace.
Social Organization
The concept of social organization is highly relevant for nurses to understand because it plays a crucial role in shaping an individual’s health beliefs, behaviors, and health-care experiences. Social organization refers to the way societies structure themselves, including their social hierarchies, roles, norms, values, and relationships. By comprehending the social structures and dynamics within a particular culture, nurses can better understand patients’ health beliefs and decision-making and health care–seeking behaviors. For example, if a woman from South Asia is nonadherent in taking her medications, it may be due to a complex social structure within her family that the husband does not believe in Western medicine and she is to comply with his will.
Factors such as socioeconomic status, access to health care, discrimination, and power differentials within societies can greatly impact health outcomes. These are known as social determinants of health. For example, an immigrant family whose members do not have transportation or English fluency may struggle with tasks such as knowing how to get to a doctor’s office or hospital. Different cultures have distinct family structures, kinship systems, and community networks that impact health-care decision-making, caregiving practices, and patient support systems. Trying to understand these dynamics can help a nurse serve as a patient advocate and connect the patient to resources. Striving to understand the social organization and its associated ethical perspectives allows nurses to navigate complex ethical dilemmas, respect cultural values, and ensure ethical care delivery.
Environmental Control
Some cultures may value the use of natural remedies or traditional healing practices that involve manipulation of the physical environment. By understanding these cultural perspectives, nurses can provide culturally appropriate care that respects and integrates patients’ beliefs and practices related to environmental control. Cultural factors, such as dietary preferences, physical activity patterns, and exposure to environmental risks, are often influenced by environmental factors. Nurses who understand the cultural concept of environmental control can help patients identify and modify environmental factors that negatively impact their health and empower them to make healthier choices and lifestyle practices that are congruent with their cultural values.
Advocating for health equity can also help reduce health-care disparities caused by an unhealthy environment. An example would be supporting public policy that advocates for safe, lead-free housing for families who have a lower socioeconomic status. Another example is supporting community initiatives or providing education on environmental health hazards, such as air pollution or tainted water.
Environmental control is particularly relevant in the context of disaster preparedness and response. Different cultures have varying knowledge, beliefs, and practices regarding environmental emergencies. Some cultures may rely on governmental agencies to rescue and recover their belongings and food supply, whereas other cultures may be self-reliant. Nurses can enable individuals and families to develop culturally sensitive disaster plans, provide appropriate education and resources, and engage communities in disaster preparedness efforts. Through recognizing the cultural dimensions of environmental control, nurses can provide culturally sensitive care, advocate for healthy environments, and empower individuals and communities to exert control over their physical surroundings resulting in improved health and well-being.
Biological Variations
The cultural concept of biological variations is essential for nurses to understand as it has a significant impact on health-care delivery and patient-centered care. Biological variations refer to the diversity and differences in human biology, genetics, and physiological processes that exist among individuals and populations. Genetic differences, metabolic variations, and susceptibility to certain diseases can vary across populations. Nurses can advocate for targeted screenings, genetic counseling, and interventions that address the specific needs of diverse populations. An example is a nurse who is aware that Ashkenazi Jewish people have an increased risk of having Gaucher disease, cystic fibrosis, and Tay-Sachs disease (National Gaucher Foundation, 2023).
Biological differences can influence how individuals understand and process health information. Nurses can tailor their communication to account for varying levels of health literacy, cultural beliefs, and individualized needs. When nurses acknowledge and validate the impact of biological factors on health outcomes, patients feel heard and understood. This fosters a therapeutic relationship built on trust, allowing nurses to deliver patient-centered care that acknowledges the unique biological needs and experiences of individuals.
Cultural Theory
While Giger and Davidhizar’s theory and model are a good starting point for understanding the importance of performing a cultural assessment, there are other theorists and models that further explore the topic. In particular, Madeline Leininger, a pioneer in transcultural nursing, and Josepha Campinha-Bacote, who takes the theories of providing culturally competent care to a new level, ask health-care providers to engage in self-reflection and to retain a stance of “cultural humility.”
Leininger’s Cultural Care Diversity and Universality Theory
Leininger’s Cultural Care Diversity and Universality Theory is a significant framework in nursing that emphasizes the importance of cultural factors in providing effective and culturally competent care. Developed by Madeleine Leininger, a nursing theorist and transcultural nursing pioneer from the University of Utah, this theory has had a profound impact on the understanding and practice of culturally congruent care. She stressed that the concept of culture was a central focus of nursing care. Her emphasis on the need for health-care professionals to develop cultural competence to provide effective care was key to really meeting the patient’s needs. She introduced her Sunrise Model, which was an interplay between cultural and professional care factors in the delivery of culturally congruent nursing care. Understanding an individual’s cultural history should include having knowledge of their heritage, migration, and historical experiences. Ideally, knowing about a patient would enhance the nurse’s ability to deliver individualized care, yet the reality often challenges the time to obtain this information for every patient.
Leininger emphasized the need for a nurse to explore the influence of cultural values, beliefs, and practices on health-care decision-making and treatment choices. Individuals express and communicate their cultural values and beliefs through language, art, and even rituals. Her conclusion was that health-care professionals should address the potential need for modifying or reorganizing medical delivery or nursing practices to promote better health outcomes as needed for the patient’s individual needs (McFarland & Wehbe-Alamah, 2019).
Link to Learning
The Transcultural Nursing Society was founded by Madeleine Leininger. It is a professional organization dedicated to promoting culturally congruent, equitable, and quality health care for all individuals. The society’s website provides valuable resources, educational materials, and research articles related to cultural competence in nursing.
It also provides information on conferences, webinars, and educational events focused on cultural comptence development and offers access to publications such as the Journal of Transcultural Nursing, which features evidence-based practices and research findings on cultural competence.
Sunrise Model
Nurses can use Leininger’s theory to conduct a cultural assessment to gather information about patients’ beliefs, values, and practices following her Sunrise Model, which depicts elements of culture (McFarland & Wehbe-Alamah, 2019). The model depicts a bridge between nursing theory and practice. Strategies for implementing culturally congruent care interventions include using cultural brokers who understand the culture, interpreters who translate language, and appropriate communication techniques, such as culturally appropriate touch or lack of touch. The model focuses on shared human needs such as physical comfort yet incorporates the overarching concept of culture as individuals from different cultures may define health, illness, and pain differently. North Americans, for example, tend to be stoic with pain compared to Latine people who may be freer to express pain in verbal manifestations. Delivering culturally congruent care considers cultural nuances to promote understanding between nurses and patients from different cultural backgrounds. Providing culturally congruent care may improve patient satisfaction, and adherence to treatment can assist the nurse in recognizing unique needs, collaborating with the patient to find ways to accommodate their needs, and explaining the rationale for medical treatment in ways the patient can understand.
Link to Learning
Read this article to learn about Madeleine Leininger and her Transcultural Nursing Theory and to see a visual of the Sunrise Model.
Campinha-Bacote’s Process of Cultural Competemility in the Delivery of Health-Care Services
Josepha Campinha-Bacote created a new word, “competemility,” which is a combination of the words “competence” and “humility” intended to guide health-care service providers through care that transcends cultural competence and addresses personal biases. The two-pronged approach of competemility asks one to be in the process of cultural humility and at the same time become culturally competent. Campinha-Bacote completed the final revision of the Process of Cultural Competemility in the Delivery of Health-Care Services in 2018. This model includes the mnemonic “A-S-K-E-D,” which challenges those in health care to pose the following self-reflective questions:
- Awareness: Am I aware of biases?
- Skill: Can I conduct an assessment in a culturally sensitive way?
- Knowledge: Do I have knowledge of different cultures and their respective health implications?
- Encounters: Do I have encounters with diverse people? Do I want conflicts in such encounters to have positive outcomes?
- Desire: Do I want to act with competemility?
Self-reflection on the A-S-K-E-D questions helps the health-care team members prepare for completing an assessment in a culturally sensitive manner.
Link to Learning
Read this article to learn more about the Process of Cultural Competemility evolution of Dr. Campinha-Bacote’s Process of Cultural Competemility in the Delivery of Healthcare Services and to see visuals of the model’s conception. Also, note the ambigram connecting “competence” and “humility.”
The Impact of a Cultural Assessment
The impact of a cultural assessment can be profound if the nurse does not identify the unique needs of the patient. When conducting a usual physical and history patient assessment, the nurse should ask about any cultural or religious needs the patient may have. Conducting a cultural assessment for each patient is essential for the following reasons:
- provides individualized care
- improves communication
- fosters trust with the patient and family members
- identifies the patient’s health beliefs and practices
- addresses health disparities
- complies with legal and ethical standards
- promotes interdisciplinary collaboration